Konstantin Puchkov – Professor, MD, the leader of the Centre of Clinical and Experimental Surgery. Member of the Society of endoscopic surgeons of Russia, Member of European Association of endoscopic surgeons, the first Russian who has become Member of Association of endoscopic surgeons of Asia.

Renal cancer

Renal tumour can be both benign and malignant. It ranks third among the oncological pathologies of the urinary system. It is mainly met in patients, aged 40, and male patients are twice more as compared to female patients.

Renal Cancer: How not to Miss it?

Symptoms of renal cancer at early stages are noticed only by few people; they think it is some other kind of disease. They think that mild pain in the lumbar area and fever in the evening are symptoms of “catching cold”; according to their mind being tired and weakness are because of the sleepless night, loss of appetite and weight is due to stress. A person visits a doctor only when blood appears in his urine; it means that tumour has grown too much. In case of a slight suspicion it is necessary to visit a doctor; and all investigations should be done.
The earlier you get a qualified aid, the more you will have chances to survive with minimum negative consequences. You should know that operation, performed on properly and on time, saves 90% of patients with the diagnosis ‘renal cancer”. In this case chemoradiation therapy is not required.

The Main Symptoms

Within the long period of time the course of the disease is without any symptoms. Then symptoms develop; the main of them is hematuria (it is blood presence in urine); one can palpate tumour in abdomen, then pain develops. Hematuria appears all of a sudden, and has short periods. Worm-shaped blood clots are sometimes found out in urine. One can palpate tumour only if its size is about 5 cm, but if patients have an excessive weight, it is difficult to do it, even if tumour is more than 5 cm. Pain is dull, and is in the area of lesion. In addition to that, a patient has weakness, temperature increase, hypertension. As a result of compression of the inferior vena cava, edema of feet and legs appears, dilatation of subcutaneous veins of the abdominal wall and varicocele develop. When metastases are spread into the tissues and organs, then symptoms, typical for an affected organ, develop: coughing and hemoptysis in case of lesion of lungs, pathological breaks of bones and pain in bones, jaundice in case of spreading of cancer cells into the liver.

When Operation is Indicated

Operation is the main method of treatment of renal tumour; the peculiarity of
this disease is sensibility absence to radial- and chemotherapy. In case, if treatment is absent, hematuria can provoke anemia development, at the latest stage blood clots can promote either ureter obturation, or tamponade of the urinary bladder; it will promote the acute delay of urination. Besides, if a patient refuses from treatment in case of malignant tumour, it will promote progressing of the disease. And metastases will be spreading all over the body, affecting organs of vital importance: liver, lungs, brain, etc.

Methods of Diagnostics

First of all, general clinical investigations should be done, then on the basis of obtained results –biochemical and cytological investigations. For clarifying the diagnosis some investigations are required: USI, excretory urography, CT.

USI-gives a possibility to visualize deformity of kidney contours, presence of necrotic areas and hemorrhage; under the guidance of USI one can take material for biopsy for histological investigation of tissues.

MRT and CT (computer tomography) are investigations that give us tissue image layer by layer. Even if the thickness of samples are minimum, it is possible to detect pathological changes in kidney. For the better effect of the investigation they use dye (a contrast substance).

Operations Performed on in Case of Renal Cancer

In most hospitals they remove the whole of the kidney, using laparotomy. But if the size of tumour is not big, it is possible to perform on an operation, preserving an organ. But if the tumour is of a big size or is located in the centre, nephrectomy (or removal) should be done. But in the clinics of Europe and the U.S.A., while treating renal cancer, the “gold” standard is a partial resection – removal of a part of kidney alongside with the tumour. And only in case, when it is not possible to perform on resection, they perform on nephrectomy – kidney removal.

Fig. 1.

Fig. 2.

Fig. 3.

Laparoscopic removal of renal tumour – resection within the boundary of healthy tissues, stitching of the renal wound.

When I perform on a miniinvasive operation for renal cancer, I always try to preserve an organ, having performed on laparoscopic resection. The kidney is exposed from the surrounding tissues, then with the help of a special ultrasonic device the localization of tumour is determined relatively to renal vessels and renal pelvis (fig.1). In case of favourable “surgical” situation resection of kidney is done-one should step aside 5-8 mm from the tumour, within the boundaries of healthy tissues, incision of formation is done, using ultrasonic scissors (fig.2). For wound stitching synthetic resorbable thread is used, as well as hemostatic glue (made in the
U.S.A.) and hemostatic system PerClot (Italy), due to them it is possible to close the renal wound properly.

In complex cases I use a stitching system V-lock (Covidien, Switzerland) that is made of monofilament resorbable polidioxanone thread with markers. Markers are oriented in space with the set angle in one direction. It gives a possibility for thread to slide in one direction and not to be shifted in another direction. These systems fix thread like anchorage, there is no need to bind knots. When using this kind of stitching system, there is better bringing together the edges of the wound (for example, if it is a uterus), it promotes better healing, and healing is 3-4 times faster. When I perform on laparoscopic nephrectomy, I compulsory remove all lymphatic nodes, where tumour cells can be located. This step is very important, because it is not possible to exclude all metastatic lesion of regional lymphatic nodes, even if you use the most contemporary diagnostic method. If you do not remove affected by metastases lymphatic nodes, later the process will be worsened. During kidney mobilization they use the modern ultrasonic surgical scissors, as well as the device of electrothermal dosed ligation of tissues “LigaSure” (U.S.A.) - due to it this stage of operation is without blood loss. A resected fragment is removed from the abdominal cavity alongside with the tumour in a special plastic container; in this way one can avoid contamination of surrounding tissues by tumour cells. At this stage a 4 cm incision on the abdominal wall is done.

I have a great experience of performing on miniinvasive operations; I have performed on about 500 operations for renal tumours - both benign and malignant. The results of performed on operations are mentioned in more than 40 scientific publications, that can be found out in different professional scientific editions, both in Russian and in foreign ones.

I have been performing on this kind of operations since 2000; within this period I have elaborated an original method of troacars positioning during laparoscopic operation, if I deal with kidney and retroperitoneal space. Instruments are located, using better angle for manipulations, that is why wound stitching of kidney in case of its resection and removal of lymphatic nodes in case of radical nephrectomy are done fast and easily.

As I know all the basic methods of renal operations, operations for cysts, benign tumours, renal cancer, I try to use some individual tactics of surgical treatment for each patient. I use operation techniques that give me a possibility to resort to laparoscopy, while the majority of surgeons perform on those operations, using laparotomic approach, for example, when there is resection of big cysts and diameter of them is more than 10 cm or in case of nephrectomy for renal cancer.

For elaboration of techniques of laparoscopic operations for renal tumour and other organs Professor K.V.Puchkov has been awarded by the most prestigious award in the field of surgery – the “GOLD LAPAROSCOPE”.

Postoperation Period

After performed on operation 3-4 incisions are left on the skin of abdomen, their length is not more than 5 mm, one incision is 4 cm long – it is used for removal of the incised organ. A patient can get up and take thin food during the first day after operation. A patient leaves the clinic in 6-8 days. Ability to work is restored in 14-21 days after operation. It is recommended to visit an oncologist and urologist from time to time; USI should be done in 3 and 6 months after operation.
Attention! It is important! In case of metastases absence in lymphatic nodes radiation- and chemotherapy are not required. After operation patients can have their usual mode of life.

If you want to make an appointment with the doctor,

«When you write me letters, you should be sure that all of them will find themselves in my e-mail. I always reply your letters myself. I remember that you trust me the most precious things - your health, your fate, your family, your nearest and dearest, and I always try to do my best to justify your trust.

Every day I answer your letters, and it takes me several hours.

When you write me letters, you can be sure, that I will learn your situation very attentively, in case of need I will ask for some additional medical documents.

A great clinical experience and thousands of successful operations will give me a possibility to understand your problem even at some distance. Many patients need not surgical treatment, but properly administered conservative treatment, but some patients need urgent surgery. In both cases I would recommend additional investigations in case of need or admitting to hospital. It is important to bear in mind that some patients need preliminary treatment of accompanying diseases in order to have a successful operation.

In your letter, please, mention your age, main complaints, your place of residence, telephone number and e-mail.

For me to be able to give you a full answer, please, forward me a scanned conclusion of USI, CT, MRT alongside with your question, as well as conclusions of other specialists. After studying your case I will forward you either my detailed reply, or a letter with some additional questions to clarify the situation. Anyhow, I will try to help you and justify your hope and trust that are the most important things for me.